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DOI: 10.1183/09031936.06.00097506
CopyrightßERS Journals Ltd 2006
EDITORIAL
uberculosis (TB) is currently the leading cause of death global TB control during the past decade [4, 5]. As of the end of
Standards
TABLE 1 Continued
Standards
Standard 13 All patients with TB and HIV infection should be evaluated to determine if antiretroviral therapy is indicated during
the course of treatment for TB. Appropriate arrangements for access to antiretroviral drugs should be made for
patients who meet indications for treatment. Given the complexity of co-administration of anti-TB treatment and
antiretroviral therapy, consultation with a physician who is expert in this area is recommended before initiation of
concurrent treatment for tuberculosis and HIV infection, regardless of which disease appeared first. However,
initiation of treatment for TB should not be delayed. Patients with TB and HIV infection should also receive
cotrimoxazole as prophylaxis for other infections
Standard 14 An assessment of the likelihood of drug resistance, based on history of prior treatment, exposure to a possible
source case having drug-resistant organisms, and the community prevalence of drug resistance should be
obtained for all patients. Patients who fail treatment and chronic cases should always be assessed for possible
drug resistance. For patients in whom drug resistance is considered to be likely, culture and drug susceptibility
testing for isoniazid, rifampicin and ethambutol should be performed promptly
Standard 15 Patients with TB caused by drug-resistant (especially MDR) organisms should be treated with specialised regimens
containing second-line anti-TB drugs. At least four drugs to which the organisms are known or presumed to be
susceptible should be used, and treatment should be given for o18 months. Patient-centred measures are
required to ensure adherence. Consultation with a provider experienced in treatment of patients with MDR-TB
should be obtained
Standards for public health responsibilities
Standard 16 All providers of care for patients with TB should ensure that persons (especially children aged ,5 yrs and persons
with HIV infection) who are in close contact with patients who have infectious TB are evaluated and managed in
line with international recommendations. Children aged ,5 yrs and persons with HIV infection who have been in
contact with an infectious case should be evaluated for both latent infection with M. tuberculosis and for active TB
Standard 17 All providers must report both new and retreatment TB cases and their treatment outcomes to local public health
authorities, in conformance with applicable legal requirements and policies
including the ‘‘complicated’’ cases, i.e. those who are sputum The ISTC, in underlining the importance of these essential care
smear negative, have extrapulmonary sites of disease, and operations, is fully consistent with WHO recommendations, as
those who are affected by MDR-TB or co-infected with HIV. described in a number of guidelines published over the years,
They are designed to put the patient at the centre of care and and complementary to local and national TB control policies.
the healthcare provider at the centre of TB control. As The ISTC document is also consistent with European
summarised in table 1, the document includes six standards Respiratory Society guidelines [9, 10].
for diagnosis, nine standards for treatment and two standards
addressing public health responsibilities. Although the ISTC is evidence based and widely accepted, it is
only a tool, not an end in itself. To achieve adherence to the
As accurate diagnosis and effective treatment are the core of ISTC, it is critical that it has sufficient ‘‘weight’’ to wield
both TB care and TB control, any clinician providing TB influence and that it is disseminated to relevant practitioners.
services to individual patients is, by definition, assuming an This can best be achieved by having the broad endorsement of
important public health function as well as providing influential medical and nursing professional societies, both
individual patient care. Thus, at the centre of the ISTC is the national and international, and that these societies develop
notion of both individual and public health responsibility. The educational activities based on the ISTC. Of key importance is
ISTC emphasises that TB diagnosis should be promptly and the close collaboration with the national TB programme and
adequately established, based, whenever possible, on bacterio- the synergistic attempt to include the ISTC among the basic
logical evidence. Internationally recommended treatment regi- tools required for the proper implementation of public–private
mens of proven quality should be prescribed, using the mix DOTS approaches.
recommended doses, and for the recommended duration, with
appropriate treatment support and supervision. The response Each healthcare provider in Europe (chest physicians and
to treatment should be monitored and microbiological exam- infectious disease specialists, in particular) should have a copy
inations performed after the initial intensive phase of of the ISTC on his/her desk, hopefully translated by an
treatment, after 5 months and at the end of treatment. The appropriate national professional society or national pro-
essential public health responsibilities are to be fully satisfied, gramme in his/her native language. This will help to improve
including evaluation and management of close contacts, as the quality of care of all TB cases and increase the proportion of
well as case notification and reporting of new cases and
treatment outcomes.
cases successfully treated, while, at the same time, achieve the
national programme targets for TB control. c
EUROPEAN RESPIRATORY JOURNAL VOLUME 28 NUMBER 4 689
INTERNATIONAL STANDARDS FOR TB CARE G.B. MIGLIORI ET AL.
The complete English versions of the International Standards for 6 China Tuberculosis Control Collaboration. The effect of
Tuberculosis Care and The Patients’ Charter for Tuberculosis tuberculosis control in China. Lancet 2004; 364: 417–422.
Care (outlining the rights and responsibilities of people with 7 Suarez PG, Watt CJ, Alarcon E, et al. The dynamics
tuberculosis) are available at www.worldcarecouncil.org. of tuberculosis in response to 10 years of intensive
control efforts in Peru. J Infect Dis 2001; 184: 473–478.
ACKNOWLEDGEMENTS 8 Tuberculosis Coalition for Technical Assistance. Inter-
The authors wish to thank T. Schaberg and V. Leimane for national Standards for Tuberculosis Care (ISTC). The
their suggestions on the manuscript. Hague, Tuberculosis Coalition for Technical Assistance,
2006.
9 Migliori GB, Raviglione MC, Schaberg T, et al. Tuberculosis
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